Seventy-eight patients with traumatic cervical spine injury (tCSI), were randomized as 38 received neostigmine and 39 received sugammadex; ultimately 37 vs 38 were included in analysis. The primary outcome was ultrasonographic LAS at 24 h. Secondary outcomes included extubation success in the OR, postoperative pulmonary complications (POPC) within 7 days, ventilator days, ICU days, tracheostomy, length of stay, and in-hospital mortality. Outcomes were assessed at 24 h (LAS) and through 7 days (POPC). Overall, the results of the study revealed no between-group difference in 24-h LAS (P=0.63) or in any secondary outcome (e.g., POPC 27.0% vs 26.3%, P=0.944). A 24-h LAS cut-off of 4 predicted POPC with AUC 0.903, sensitivity 80%, and specificity 87.3%. In short, sugammadex did not improve postoperative lung aeration or clinical pulmonary outcomes versus neostigmine in tCSI; LAS itself may be useful for POPC risk stratification.